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Listen to Health Affairs Editor-in-Chief Alan Weil interview Arturo Vargas Bustamante from UCLA on the health of immigrants in the US today and how the shifting demography of the nation affects health policies.
Each week, Health Affairs' Rob Lott brings you in-depth conversations with leading researchers and influencers shaping the big ideas in health policy and the health care industry.
A Health Podyssey goes beyond the pages of the health policy journal Health Affairs to tell stories behind the research and share policy implications. Learn how academics and economists frame their research questions and journey to the intersection of health, health care, and policy. Health policy nerds rejoice! This podcast is for you.
Hello, and welcome to A Health Policy.
Speaker 2:On average, immigrants are more likely to be to have better self reported health status and lower incidence of chronic health conditions compared to US born adults.
Speaker 1:I'm your host, Alan Weil. The number of immigrants living in the United States has increased fourfold since the 19 sixties with 1 in 7 residents now an immigrant. Immigrants face unique challenges obtaining health care services, some caused by explicit policies designed to limit or exclude immigrants from programs or benefits available to people born in the United States. Other access barriers relate to immigrants on average lower household income or greater likelihood of having limited English proficiency. The health of immigrants in the United States is the topic of today's health policy.
Speaker 1:I'm here with Arturo Vargas Bustamante, professor of health policy and management at the UCLA Fielding School of Public Health. Doctor. Bustamante and co authors published a paper in the July 2021 issue of Health Affairs describing a range of health policy issues raised by the shifting demography of US immigrants over the past 2 decades. They explored health insurance, health status, and access to care across the immigration and citizenship continuum and found that inequities between immigrants and US born residents increased after the great recession and began to decline after the Affordable Care Act took effect. Doctor.
Speaker 1:Bustamante, welcome to the program.
Speaker 2:Thank you very much, Alan. I'm very happy to be here today.
Speaker 1:I'm so happy to have you as our guest today. Let's just start with sort of a profile of immigrants in the United States. Give us some of the basic statistics. How many are there? Where have they immigrated from?
Speaker 1:What are the trends? What what do we know about their legal status? Just a little bit of an overview here.
Speaker 2:Sure. To answer your question, let me first provide a very quick summary of the immigrant population in the US. In 2018, close to 45,000,000 immigrants lived in the country. This represented approximately 14% of the overall population. The current profile of the immigrant population originates in the Immigration and Nationality Act of 1965.
Speaker 2:This legislation practically abolished national origin admission quotas, which led to important changes in the racial and ethnic composition of immigrants in the US. Before the 19 sixties, US immigrants were overwhelmingly of European origin. However, since the 19 sixties, US immigrants have been more likely to originate in Latin America and Asia. Changes in the demography of immigrants are likely to continue in the upcoming decades. As we mentioned in the article, immigration from Mexico has slowed considerably since the great recession.
Speaker 2:Starting in 2009, the US has received an increasing share of Asian immigrants, while the flow of Latin American immigrants started to decline. If present trends continue, immigrants from Asia are projected to become the largest group of immigrants by 2,055. A very important change in the profile of US immigrants happened since the great recession of 2,008, when we started to observe 2 very interesting changes among, immigrant populations. And the first was a rapid decline of low skilled immigration and an increase in the education attainment of immigrants. In 1960, only 2.5 percent of immigrants had a college degree and 2.6 percent of immigrants had a postgraduate degree.
Speaker 2:By 2018, 18.1 percent of immigrants had a college degree and close to 14% had a post graduate degree. A second important change was the place of residence of US immigrants. Historically, states such as California, Florida, New Jersey, and New York hosted the majority of immigrants. These states had the main ports of entry. Since the early 2000s, immigrants started to move all across the US and into states that were not traditional immigrant destinations.
Speaker 2:States like Georgia, Oregon, Maryland, and Virginia rapidly became new immigrant destinations, where immigrants have already surpassed the 10% threshold of the state population. And to answer the last part of your question about the legal status of immigrants, in the previous decade, the undocumented immigrant population in the US has experienced demographic shifting as well. The undocumented immigrant population reached more than 12,000,000 people in 2,007, but its numbers have been in decline since the Great Recession. Something important to note is that close to half of all undocumented immigrants live in 3 states. These are California, Texas, and New York.
Speaker 2:Another interesting trend is that the majority of undocumented immigrants were born in Mexico. 47%. However, Mexican undocumented immigrant population has been in decline for almost a decade. Right now, recent arrivals in the US Mexico border are more likely to be from countries other than Mexico.
Speaker 1:Well, so we have this just very complex history as a country. You've only gotten back to 1960 but, of course, the story goes, centuries back. In your paper, you describe an immigration and citizenship continuum. What do you mean by that phrase? I hadn't heard it before.
Speaker 2:Sure. Well, this is this term refers to the different trajectories that US immigrants follow since they first moved to the US until they become US citizens. More recent immigrants are classified as non citizen immigrants. After a few years in the US, temporary immigrants with a valid visa usually become permanent residents when they receive the so called green cards. And 5 years after becoming permanent residents, immigrants are eligible to become US citizens.
Speaker 2:This immigration and citizenship trajectory is important for health policy researchers because immigrants have different eligibilities to public health programs in each stage. For example, non citizen and permanent residents with 5 years or less of US residents are ineligible to enroll in Medicaid in many states, or they are eligible to receive only limited services from Medicaid. However, when immigrants get a green card and live in the US for more than 5 years, they essentially have the same eligibility to public health insurance programs, such as Medicare or Medicaid, as US born citizens. From a research perspective, we observe more widespread differences in terms of health outcomes and access to care between non citizen immigrants and US born adults compared to the differences between naturalized immigrants and US born adults that are almost non existent. Just to mention one example from our study, the uninsured rate of non citizens who have lived in the US for 5 years or less is 3 times larger than the uninsured rate among US born adults.
Speaker 2:In the article, my co authors and I go in-depth through multiple measures of health outcomes and access to care. However, the trends are very similar and consistent with previous research. More recent immigrants look quite different when we compare them with US born adults. However, more established immigrants who already have a green card or those who have already become US citizens resemble US born adults in terms of health outcomes and access to care. And the reasons for this convergence in health outcomes and access to care over time is due to 2 factors.
Speaker 2:And the first one is access to care. As I mentioned before, recent immigrants have some restrictions in the type of public insurance programs they can access, but they are also less familiar with the US health care system. So access to care among recently arrived immigrants is usually low and restricted. The second factor is the process of acculturation. Over time, immigrants learn their way into US society and its health system.
Speaker 2:With acculturation, the profile of immigrants also tend to mirror that of the US born. Several factors contribute to this trend, such as the changes in health behaviors and social determinants of health that immigrants encounter when they live in the US.
Speaker 1:Yeah. So many of us when we study this, much less in-depth than you have learned that immigrants on average are actually healthier than those who are born in the US. But in your paper, you describe a more complex picture, and I think it's tied to the heterogeneity of the population that you, discussed at the outset. What do we know about the health of immigrants living in the US?
Speaker 2:Yes. Previous research on immigrant health shows that, on average, immigrants are healthier compared to the US born population. In our study, we analyzed recent data and confirmed these findings. On average, immigrants are more likely to be to have better self reported health status and lower incidence of chronic health conditions compared to US born adults. And we can explain this difference due to three factors.
Speaker 2:The first one is demographic differences. In the US and older developed countries, immigrant populations are more likely to be younger compared to the native population, and younger adults are on average experience better health outcomes and are less likely to use health care compared to older adults. 2nd is a concept that researchers call the healthy immigrant effect, which means that immigrants on average are more likely to have better health outcomes compared to the populations in its origin and destination countries. The reason for this is that not everyone in ascending country would have the same motivation, physical, and mental strength to emigrate to a foreign country. So those who ultimately emigrate will have particular characteristics that researchers call immigrant self selection, that in health care research translates into better health outcomes.
Speaker 2:The third reason why, on average, immigrants seem to have better health is, ironically, poor access to care. Better self reported health status and lower incidence of chronic conditions among immigrants could partly be explained by under diagnosed chronic conditions among under served immigrants due to poor access to health care. In our study, it is important to note that undocumented immigrants were likely to report fair or poor health at higher rates compared to US born adults. But this important advantage is only visible when we pull all immigrants together as a group. When studies analyze immigrants from specific countries or compare particular health conditions, differences between immigrants and US born adults many times narrow or disappear.
Speaker 2:One good example is mental health. Immigrants on average have lower prevalence of mental health conditions compared to US born adults. However, when studies look at immigrants from countries experiencing war, violence, and conflict, immigrants report much higher prevalence of mental health conditions. So differences with US born out narrow or disappear.
Speaker 1:Well, you've given us a very thorough picture of the health, status of the immigrant population. I wanna dive more deeply into the policy side of this, why some of those gaps exist, and what we might do about them. We'll have that conversation after we take a short break.
Speaker 3:COVID 19 has reshaped American life along the way. Health affairs has published research and perspectives on the novel coronavirus. Our free COVID 19 resource center collects blogs and fast track journal articles so you never miss the latest perspective from the health policy community. Highlights include an audio series from NYC Health and Hospitals on their early response efforts. Visithealthaffairs.org backslashcovidash19 to stay up to date.
Speaker 1:And we're back. I'm speaking with Arturo Vargas Bustamante. Before the break, we were getting a very comprehensive picture of the health status of immigrants, and now I wanna turn more to the policy side. You mentioned that there are major gaps in coverage and access to care for immigrants regardless of their immigration and citizenship status. Tell us what those gaps are.
Speaker 2:As I mentioned before, immigrants are less likely to have health insurance and have worse patterns of access to health care compared to US born adults. And these disparities are exacerbated by citizenship and documentation status. In our study, we find that length of US residents, documentation status, and English language proficiency are key predictors of health insurance coverage and access to health care among immigrants. We also look at how these measures evolved, from 2,004 until 2018. We identified that differences in terms of health insurance coverage and access to care increased after the great recession and later diminished after the implementation of the Affordable Care Act.
Speaker 2:Healthcare inequities remain, particularly among non citizen immigrants. In our study, we also looked at health care differences in health insurance coverage and access to health care for both documented and undocumented immigrants. In our research, we find the differences between undocumented immigrants and US born adults are the more widespread.
Speaker 1:Now you mentioned these 2 seminal events in, the last few decades, the great recession and then the adoption of the Affordable Care Act. You talked about how the composition of immigrants changed in the wake of the recession, but there were some policy changes in the Affordable Care Act that affected, coverage for immigrants. Can you describe how health insurance coverage for immigrants has changed in the wake of the ACA?
Speaker 2:Yes. In our study, we find that the ACA had very positive impact by reducing inequities between the immigrant population on average and US born adults. However, important differences remain among immigrants. The main reason for this is that the ACA increased eligibility among all legally authorized immigrants. These are documented immigrants, but it excluded undocumented immigrants.
Speaker 2:This left this population ineligible to access the health insurance exchanges, for example, or the, Medicaid expansion in some states that didn't expand Medicaid.
Speaker 1:One of the interesting, statements in your paper is that the US health care system is largely unprepared to deal with an aging immigrant population. I think much of the public attention to immigration and immigrants is to younger people as they are making their way into the country. But again, we've had a large immigrant population for decades and and since the founding of the country. What do you mean when you say the system is unprepared to deal with an aging immigrant population? Why and why do you say that?
Speaker 2:Right. The immigration research community right now is coming to this realization, right, and as we discussed in this study, an increasing number of aging undocumented immigrants who have lived and worked for many years in the US are still ineligible for Medicaid and Medicare. Before the 2000s, this was not a big problem because circular migration eased the health care demands from aging immigrants. And just
Speaker 1:just to make sure, circular, I assume, means people come here and then when they are at the later stages in life, they return to their country of origin?
Speaker 2:Right. Since, many times, immigrants came to the US, worked for a few decades, and then they came back to their home countries where they spent their older adults' lives. So this is, the process in the immigration community that is called circular migration. More recent immigrants, however, are more likely to settle in the US. Immigrants are also aging faster compared to US born adults.
Speaker 2:In fact, the aging process among immigrants is currently faster than the aging process among the US born population. If present trends continue, longer periods of US residents and a declining number of new immigrants significantly contribute to patterns of immigrant aging. From a health policy perspective, the US health care system is largely unprepared to deal with aging immigrants, particularly uninsured immigrants who live in states where they are ineligible for Medicaid and undocumented immigrants who are ineligible for Medicare. Aging immigrants may even find it challenging, those who are documented to qualify for Medicare since they need to account for at least 10 years of Social Security earnings to be eligible.
Speaker 1:We focused a lot on the health side of immigration policy, Medicaid eligibility, and the like. But, of course, all of this plays out in the context of a broader set of policies with respect to immigration. Are there particular aspects of those policies that you view as either supportive or potentially harmful to the health of immigrants?
Speaker 2:Sure. Immigration policy has great potential to improve health outcomes and access to care among immigrants by expanding eligibility to public health insurance programs. In our study, we recommend that immigration reform should close the coverage gap left by the ACA among US immigrants, particularly in states that have not expanded Medicaid. We provide two examples of Medicaid coverage expansion to undocumented young adults and older adults in California. These are examples of policies at the state level that can partly address health care inequities between immigrants and US born adults.
Speaker 2:However, previous research shows that increasing eligibility is not a precondition of optimal use of health services. While immigrant families may be eligible for certain health services in the US, they may choose to forego needed health care and social services as a consequence of restrictive immigration policies. In the long term, the under use of health care due to fear of immigration enforcement can have negative health outcomes among immigrants by discouraging access to needed care. In fact, the criminalization of immigration policy that has happened in the recent years negatively impact health outcomes of immigrants through added stress about the consequences of immigration enforcement in mixed status families. The criminalization of immigration enforcement through stringent immigration policies has also contributed to overcrowding in detention facilities, which can lead to outbreaks of infectious diseases such as COVID-nineteen.
Speaker 2:This is why one of the main recommendations of our study is to include public health considerations in immigration enforcement to respect the human rights of repatriated immigrants. To conclude, our study recommends increased access to affordable health insurance coverage to help protect immigrant household incomes and encourage optimal access to health care. While the odds of comprehensive immigration reform are low, in our study, we provide examples of incremental reform at the federal, state, and local levels that can partly expand health care to underserved immigrants.
Speaker 1:So I wanna ask you questions that I didn't prep you for, and I'm not sure how we'll use them, but I just they've come up and I wanna, just get your take on them. So one is we think of Medicare as a universal program for people over 65. But as you point out, if you don't have 40 quarters of social security, income, you actually aren't eligible. And, for younger people where we have unfortunately large numbers of people who are uninsured, we have various types of safety net systems in place. But for older Americans where coverage is almost universal, those safety net systems just sort of don't exist because the numbers are so small.
Speaker 1:So what are the implications of being an an immigrant who's, you know, over 65 aging without access to the program that we consider the cornerstone of universal coverage in this country and that is Medicare.
Speaker 2:Right. Like many times even immigrants contribute to Medicare, as some research that we cite in our paper shows, but they are not eligible for it mostly because they use the Social Security numbers of other people or because they are not US citizens at the time that they become eligible for Medicare. So the implications are huge for this population because older adults are in need of better coordinated care for, different types of conditions. All the the the aging process among immigrants is also likely to be more to require more care compared to the aging process of people who have regular access to health care. So it's a population that has potentially higher need of comprehensive, well coordinated health care that is currently available through Medicare for those individuals who are eligible for it.
Speaker 2:However, if immigrants are not eligible for it, they could access, community clinics in the safety net systems. However, that regular access to providers, prescriptions, their physical therapies, and all the services that are available through Medicare are not available to them. And over time, this could potentially increase the vulnerability and worsen access to health care and health outcomes among these aging populations.
Speaker 1:Well, I've learned a great deal about a very important subject and it's complex and one that is certain to be with us for some time. So, doctor Bustamante, thank you so much for joining me on A Health Policy.
Speaker 2:Thank Thank you very much for having me.
Speaker 1:Thanks for listening. If you enjoyed today's episode, I hope you'll tell a friend about a health policy.
Speaker 3:Health Policy is produced by Health Affairs, the leading journal for health policy research. The team behind the show includes Patty Sweet, Jeff Byers, Julia Vivolo, Sarah Culp, and Sue Ducat. Like the show? Subscribe to a Health Podyssey on Apple Podcast, Spotify, Stitcher, Google, or wherever you listen to your favorite podcasts. Thanks for listening, and have a great morning, day, or evening.